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Practice Test 5 - NAPLEX

20 questions. Answer them in any order, then submit to see your score and every explanation.

  1. A 59-year-old male (weight 85 kg, height 176 cm) with deep vein thrombosis is receiving enoxaparin 80 mg subcutaneously every 12 hours. Past history: chronic kidney disease. Current medications: acetaminophen 650 mg every 6 hours as needed and sertraline 50 mg daily; allergies: none. Labs: serum creatinine 2.6 mg/dL, aspartate aminotransferase 21 U/L, alanine aminotransferase 20 U/L, hemoglobin 12.8 g/dL, platelets 210 x103x10^3/mm3mm^3; anti-factor Xa level (drawn appropriately) is 1.4 IU/mL (typical treatment peak goal ~0.6–1.0 IU/mL). Therapeutic goal: therapeutic anticoagulation while minimizing bleeding. What is the appropriate dose adjustment given the patient's renal function?
  2. A 67-year-old woman (weight 70 kg) with nonvalvular atrial fibrillation and hypertension is starting anticoagulation; her creatinine clearance is 55 mL/min. A randomized, open-label, blinded-endpoint trial compared apixaban 5 mg twice daily vs warfarin (international normalized ratio goal 2–3) for stroke/systemic embolism prevention; annual stroke/systemic embolism rates were 1.27% vs 1.60% (hazard ratio 0.79, 95% CI 0.66–0.95; p=0.01) and major bleeding was 2.13% vs 3.09% (hazard ratio 0.69, 95% CI 0.60–0.80; p<0.001). What is the key takeaway from the study for this patient's case?
  3. A 39-year-old woman with low income presents to the pharmacy with a new prescription for levothyroxine 75 mcg by mouth daily. Medical history: hypothyroidism. Current medications: levothyroxine 75 mcg daily, calcium carbonate 500 mg by mouth twice daily as needed for heartburn; no known drug allergies. She has no insurance, lives in a rural area, and cannot afford follow-up thyroid-stimulating hormone testing; a local community clinic offers discounted labs once monthly. Which factor is most critical to consider in this patient's care plan?
  4. A 63-year-old female (weight 66 kg, height 158 cm) with chronic pain presents with excessive sedation and slowed breathing after starting a new medication yesterday. Current medications: oxycodone immediate-release 10 mg by mouth every 6 hours as needed (uses 3–4 doses/day), gabapentin 600 mg by mouth three times daily, and a new prescription for diazepam 5 mg by mouth three times daily for muscle spasm; allergies: none known. Labs: serum creatinine 0.9 mg/dL (0.6–1.3), alanine aminotransferase 22 units/L (7–56). The prescriber did not document counseling or risk mitigation, and no naloxone was offered. What is the most critical error in this scenario?
  5. In a busy retail pharmacy, a technician accidentally selects hydralazine 25 mg instead of hydroxyzine 25 mg during data entry; the pharmacy system's tall-man lettering and indication prompts are enabled, but the prompt was dismissed. The pharmacist notices the mismatch when reviewing the e-prescription and the patient's EHR-linked problem list shows chronic pruritus. The pharmacist must use available informatics tools to prevent the error and document appropriately. How should the pharmacist utilize the EHR to improve medication safety?
  6. A 63-year-old man (88 kg) with heart failure with reduced ejection fraction (LVEF 30%) reports new breast tenderness and enlargement after starting spironolactone 25 mg PO daily 3 months ago. Current medications: sacubitril/valsartan 49/51 mg PO BID, carvedilol 25 mg PO BID, spironolactone 25 mg PO daily, furosemide 40 mg PO daily. Labs: K 4.7 mEq/L, SCr 1.1 mg/dL, AST/ALT normal; allergies: none. Which source provides the best evidence-based recommendation for managing spironolactone-associated gynecomastia while maintaining mortality benefit in HFrEF?
  7. In a hospital ICU, a 68-year-old male (82 kg) with atrial fibrillation is ordered a heparin infusion for VTE prophylaxis/therapeutic anticoagulation; the nurse calls because the MAR shows both heparin 25,000 units/250 mL (100 units/mL) and heparin 25,000 units/500 mL (50 units/mL) stocked on the unit. Current meds: metoprolol tartrate 25 mg PO BID, lisinopril 10 mg PO daily, atorvastatin 40 mg PO nightly. Labs: SCr 1.1 mg/dL, AST/ALT 28/32 U/L, INR 1.1, A1c 6.2%; allergies: none. The risk is a high-alert infusion concentration mix-up leading to a 2-fold dosing error. What is the best practice for handling this high-alert medication?
  8. A meta-analysis pooled 6 trials (n = 4,100; mean age 50 years; 64% female) comparing an SSRI vs placebo for generalized anxiety disorder. The pooled response odds ratio was 1.40 (95% CI 1.15 to 1.70; p = 0.001). What is the primary conclusion from the meta-analysis?
  9. A 31-year-old female (60 kg) presents with flushing, sweating, lacrimation, wheezing, and muscle fasciculations after using an insecticide in a poorly ventilated apartment; she is drooling and has pinpoint pupils. Current medications: albuterol inhaler 2 puffs every 4 hours as needed. Labs: serum creatinine 0.7 mg/dL; aspartate aminotransferase 24 units/L; alanine aminotransferase 20 units/L. Allergies: none. History: asthma; exposure was 30 minutes ago. Which antidote is most appropriate for this exposure?
  10. A 34-year-old male (86 kg) calls the pharmacy 30 minutes after taking his first dose of amoxicillin/clavulanate 875/125 mg by mouth twice daily for sinusitis. He reports new generalized hives, lip swelling, and tightness in his throat. Current medications: none. Allergies: seasonal allergies only. Medical history: none. No labs available. What is the most important step in reporting this adverse drug reaction?
  11. In an acute care unit, a nurse reports that the automated dispensing cabinet (ADC) dispensed hydromorphone 2 mg/mL vials when morphine 2 mg/mL vials were selected for restocking. The pharmacy informatics dashboard shows the ADC bin for morphine was recently reassigned after a formulary change, and the hospital requires controlled substance discrepancies to be investigated and documented per policy. Which informatics tool is most appropriate for resolving this medication error?
  12. A 67-year-old male (82 kg) is hospitalized for community-acquired pneumonia and was started empirically on piperacillin/tazobactam 3.375 g IV every 6 hours plus vancomycin 1.25 g IV every 12 hours 48 hours ago. Current medications also include lisinopril 10 mg PO daily and acetaminophen 650 mg PO every 6 hours as needed. Labs: SCr 1.0 mg/dL; AST/ALT 22/19 units/L; WBC 9.8 x103x10^3/mcL; procalcitonin decreased from 1.8 to 0.4 ng/mL. Sputum culture grows Streptococcus pneumoniae susceptible to penicillin and ceftriaxone; MRSA nasal PCR is negative; blood cultures show no growth. Allergy: rash to sulfonamides. Which intervention is most appropriate for this patient's antimicrobial therapy?
  13. A 66-year-old man (weight 85 kg) is admitted with severe pain from metastatic prostate cancer; treatment goal is continuous analgesia with minimal peaks and troughs. Current medications: morphine immediate-release 15 mg orally every 4 hours as needed (insufficient), ondansetron 4 mg orally every 8 hours as needed. He has difficulty swallowing pills due to mucositis. Labs: serum creatinine 1.0 mg/dL. Allergies: none. Which administration route is most appropriate for this patient?
  14. A 29-year-old woman (weight 70 kg) with Crohn disease is seen in clinic for maintenance therapy. She has been stable for 8 months on infliximab (Remicade) 5 mg/kg intravenously every 8 weeks; last infusion was 7 weeks ago. Current medications: infliximab as above, azathioprine 100 mg by mouth daily, multivitamin daily. Your health system has added infliximab-dyyb (Inflectra) as the preferred product and the prescriber asks you to switch her at the next infusion. What is the best approach to substituting a biosimilar for this patient's medication?
  15. Absorbed fraction is 0.8; oral F is 0.5. Hepatic extraction ratio? (Assume no gut metabolism.)
  16. A 41-year-old man (90 kg) presents with 3 days of watery diarrhea and abdominal cramping after completing clindamycin 300 mg four times daily for 10 days for a dental infection. Medical history: none. Current medications: none besides recent antibiotic. Allergies: none. Labs: white blood cell count 14,500/mm3mm^3 (normal 4,000–11,000), SCr 1.0 mg/dL. Which condition is most consistent with this patient's symptoms?
  17. A 62-year-old man (91 kg) with gout presents for follow-up after starting allopurinol 4 weeks ago. PMH: gout, CKD stage 3b, HTN. Meds: allopurinol 300 mg PO daily, colchicine 0.6 mg PO daily (prophylaxis), losartan 50 mg PO daily. Labs: SCr 2.1 mg/dL (eGFR 32 mL/min/1.73 m2^2), uric acid 5.8 mg/dL, CBC WNL, LFTs WNL. He reports no flares and mild diarrhea. Which parameter should be closely monitored for effectiveness?
  18. A 34-year-old female is prescribed progesterone vaginal inserts from a retail pharmacy. The product labeling states to store at controlled room temperature 20–25°C (68–77°F) and avoid excessive heat. She plans to travel internationally and asks whether she should pack them with dry ice. Which recommendation ensures optimal stability for this drug?
  19. A pharmacy experiences a break-in overnight and multiple bottles of Schedule II opioids are missing. The pharmacist-in-charge is determining next steps. Under DEA requirements, how should the pharmacist respond to this controlled substance loss?
  20. A 82-year-old woman (weight 50 kg) with atrial fibrillation has new-onset delirium and cannot swallow safely; treatment goal is continued rate control. Current medications: metoprolol succinate 50 mg orally once daily (extended-release), apixaban 5 mg orally twice daily. Blood pressure is 128/74 mmHg and heart rate is 92 beats/min. Allergies: none. Which administration route is most appropriate for this patient?

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